In a deal similar to
the one that turned the tide against AIDS, manufacturers and
charities will make chemotherapy drugs available in six poor countries at steep discounts.
charities will make chemotherapy drugs available in six poor countries at steep discounts.
By DONALD G. McNEIL Jr. OCT. 7, 2017
NAIROBI, Kenya — In a remarkable initiative modeled on the
campaign against AIDS in Africa, two major pharmaceutical companies, working
with the American Cancer Society, will steeply discount the prices of cancer
medicines in Africa.
Under the new agreement,
the companies — Pfizer, based in New York, and Cipla, based in Mumbai — have
promised to charge rock-bottom prices for 16 common chemotherapy drugs. The
deal, initially offered to a half-dozen countries, is expected to bring
lifesaving treatment to tens of thousands who would otherwise die.
Pfizer said its prices would be just above its own manufacturing
costs. Cipla said it would sell some pills for 50 cents and some infusions for
$10, a fraction of what they cost in wealthy countries.
The price-cut agreement comes with a bonus: Top American
oncologists will simplify complex cancer-treatment guidelines for underequipped
African hospitals, and a corps of IBM programmers will build those guidelines
into an online tool available to any oncologist with an internet connection.
“Reading this gave me goose bumps,” Dr. Anthony S. Fauci,
director of the National Institute of Allergy and Infectious Diseases, said
after seeing an outline of the deal. “I think this is a phenomenal idea, and I
think it has a good chance of working,”
It reminded him, he said, of his work in 2002 helping design the
President’s Emergency Plan for AIDS Relief. Pepfar, as it is known, has been a
success: over 14 million Africans are now on H.I.V. drugs, many of them thanks
to American aid.
“It’s exactly what we went through then,” Dr. Fauci said.
“Finding the countries with the highest burden, figuring out how to approach
treatment differently in each one, and getting the prices down.”
Cancer now kills about 450,000 Africans a year. By 2030, it will
kill almost 1 million annually, the World Health Organization predicts. The
most common African cancers are the most treatable, including breast, cervical
and prostate tumors.
But here they are often lethal. In the United States, 90 percent
of women with breast cancer survive five years. In Uganda, only 46 percent do;
in Gambia, a mere 12 percent do.
The complicated deal was struck by the cancer society, along
with the Clinton Health Access Initiative, founded in
2002 by former President Bill Clinton; IBM; the National Comprehensive Cancer
Network, an alliance of top American cancer hospitals; and the African Cancer
Coalition, a network of 32 oncologists in 11 African countries.
“I have a friend back home whose daughter has cancer, and I
can’t believe the outpouring of support she got, like special lacrosse games
and T-shirts,” said Megan O’Brien, the cancer society’s director of global
cancer treatment and the chief organizer of the deal.
“There’s nothing like that in Africa — but I can save a child
with leukemia for $300. That’s a disease that has a 90 percent cure rate in
America, and a 90 percent death rate in Africa.”
An Ill-Prepared Continent
As more Africans survive into middle or old age, cancer rates
are climbing rapidly. But most countries here are ill-equipped for the fight.
There are few oncologists, radiotherapy machines or advanced
surgical suites. Tumors are often misdiagnosed or even blamed on witchcraft,
and 80 percent go undetected until they have spread to lymph nodes or distant
organs.
Doctors often see cases far worse than Western doctors ever do:
babies with growths half as big as their heads, women with breast tumors the
size of softballs that have broken the skin, putrid and weeping blood.
On a recent day in July, Brenda Nakisuyi, 17, sat silent and
despondent in a darkened room at Kawempe Home Care, a cancer hostel for
children in Kampala, Uganda.
Burkitt lymphoma had torn open her left cheek, leaving a crater
that looked as if a cherry bomb had exploded in her mouth.
“In our village, they know malaria, they know HIV, they know
typhoid — but they don’t know cancer,” said her mother, Florence Namwase, 48.
“People said Brenda was bewitched, and they began to shun her.”
Many Africans who get cancer assume they are doomed.
“I came here to see if I was condemned to death,” said a wry
George Odongo Ogola, 73, a retired high school principal being treated for
prostate cancer at the M.P. Shah Hospital in Nairobi.
“But the doctor says they got it in a nascent stage and gave me
a 99.9 percent chance that it will be contained,” he added. “I brought all my
children and their wives so they could hear this. Here, once you are diagnosed
with cancer, they treat you like a dead person.”
Even doctors — especially rural ones — may be slow to recognize
the disease.
Paul Mugumya, a lively 7-year-old in the Kawempe hostel, had
three hernia operations before surgeons realized that something else was
swelling his abdomen, which now has a football-shaped tumor with
tangerine-sized blisters on it.
And Flavia Anyesi, 4, who stood in her crib at the Uganda Cancer
Institute in pink and white hair beads matching her pink nightgown, was first
sent to a dentist to have a tooth pulled, said her mother, Teopista Nafuna.
Only when Flavia’s jaw kept swelling did doctors realize
something else was amiss. She, too, has Burkitt lymphoma.
Even when in agony, victims may be too poor to travel for
treatment. Patients who find the money to reach urban hospitals often sleep on
mats on the verandas or in parks between their daily infusions, or while
waiting for biopsy results, which can take weeks.
“When you are not well and you are sleeping under trees, can you
really rest in peace?” asked Proscovia Mutesi, 50, a former school secretary
who has lost an eye and part of her jaw to cancer.
Sitting on the bed she recently found at the Cancer Charity
Foundation, a Kampala adult hostel, she recounted a seven-year battle to slow
down the tumor gnawing away her face.
“I have struggled,” she said. In some years, she was able to
raise $110 for a course of chemo or $85 for radiation.
“But in some, I did not have a coin. And then the radiation
machine collapsed.”
If there is little treatment, it is partly because there are so
few cancer specialists.
Ethiopia, one of the six countries covered by the new agreement,
has only four oncologists for its 100 million citizens. Nigeria has about 40
for its population of 186 million.
Uganda’s national hospital campus boasts a cancer institute that
was founded in 1967, and it has a spotless new clinical trial building erected
by the Fred Hutchinson Cancer Research Center.
But the country has only 16 oncologists, and its only
radiotherapy machine — the one that Ms. Mutesi relied on — has been broken for
over a year.
Before its 21-year-old gears gave out, the machine’s cobalt
source had become so weak that irradiation sessions meant to last minutes took
an hour.
Counterfeit Drugs
Almost everywhere in Africa, cancer drugs are in scarce supply,
and prices remain a huge obstacle.
Small orders mean hospitals pay more per vial and often must
settle for whatever brands are available, sometimes even those smuggled in by
what is bitterly called “donkey import.”
Currently, the W.H.O. does not certify which brands of cancer
drugs are safe and effective, as it does those for AIDS and malaria.
“In terms of quality, you cannot tell for sure, you just trust,”
said David E. Wata, an oncology pharmacist at Kenyatta, the country’s top
public hospital.
Africans with the means usually seek treatment in India or South
Africa. Those with political connections sometimes go at government expense,
draining national treasuries.
The poor must fend for themselves. If the shelves of public
hospital pharmacies are bare, patients and their families seek out private
ones, which may carry low-quality drugs or counterfeits.
“There’s nothing more tragic than seeing a family spend
everything they have and get nothing,” Dr. O’Brien said. “Sometimes the first
sign that it’s not working is that they don’t lose their hair.”
The 16 drugs that Pfizer and Cipla will sell have unfamiliar
names like vinblastine, bleomycin and fluorouracil. They are old standbys of
chemotherapy and now available as generics.
“These 16 won’t be enough — they’re about half the range we
need,” said Moses Kamabare, general manager of Uganda’s National Medical
Stores, the health ministry’s purchasing arm.
“But in terms of value, they are about 75 percent of our current
oncology budget. So we are really, really grateful for a chance to get better
quality at a better price.”
Drugmakers’ attitudes toward helping Africa have changed since
the late 1990s, when Western companies were pilloried for refusing to lower
prices on their AIDS drugs as millions here died.
Now nearly all companies offer a combination of donations and
“tiered pricing,” under which they charge poor countries a small fraction of
what they charge rich ones — but impose safeguards to prevent smuggling of
their products into wealthy markets.
Companies compete to rise higher on the Access to Medicines
Index, which ranks them on how well they do at getting their
products to the world’s poor.
John Young, president of Pfizer’s essential health group, said
the price-cut deal differs from Pfizer’s charitable donations, like the 500
million antibiotics doses it provided to help eliminate the
eye disease trachoma.
“The challenge of pure philanthropy is that it’s not infinitely
sustainable,” Mr. Young said. “We expect to make no money on this — but we also
don’t want to lose money.”
The company will charge enough to cover just its manufacturing
and packaging costs, not those related to research, marketing or advertising,
he said.
Cipla’s prices, said Dr. Denis Broun, the company’s head of
governmental affairs, will be as low as one-eighth of what it charges for
generics in the United States. The company hopes to start making cancer drugs
soon at its factories in Uganda and South Africa, he added.
A Strategy for Poor
Nations
Cipla has a long tradition of serving poor countries. In 2001,
its chairman, Yusuf K. Hamied, shocked the
global pharmaceutical industry by offering a triple-therapy
AIDS cocktail for $350 a year to Doctors Without Borders at a time Western
companies were charging $12,000.
That offer set off a price cascade that in turn led to the creation of
donor agencies like Pepfar and the Global Fund to Fight AIDS,
Tuberculosis and Malaria.
The current deal started taking shape two years ago, when Dr.
O’Brien, an epidemiologist and palliative care expert, convinced the leadership
of the American Cancer Society to give the Clinton Health Access Initiative a
grant to study the market and approach pharmaceutical companies.
The initiative, known as CHAI (pronounced “chy”), is largely
independent of the better-known Clinton Foundation, though Mr. Clinton and his
daughter, Chelsea, are on its board.
Foreign donations to
the foundation while Hillary Clinton was secretary of state raised questions of
conflict of interest during her presidential campaign. Had Mrs.
Clinton won, the family and former White House staffers would have resigned
from CHAI’s board, and it would have dropped
the Clinton name.
For several years, Dr. O’Brien was chief of H.I.V. mathematical
modeling at CHAI.
CHAI has not previously worked in cancer, but the organization
has long experience negotiating low prices for drugs and vaccines for poor
countries, finding donors to pay for them, and overcoming obstacles like red
tape, corruption and shortages of refrigerated trucks to ensure delivery.
Other drug makers will eventually be asked to consider selling other
chemotherapy drugs, the initiative’s chief executive, Ira C. Magaziner, said in
an interview. The first 16 to be made available now are those
most urgently needed.
Mr. Magaziner feared that having too many suppliers at first
could mean that all would lose money if the initial orders were small.
“It’s very early days, so I don’t want to say we’ve accomplished
much yet,” he said. “But we will accomplish things that are significant. It’s
going to be at least a 15-year battle to get treatment close to Western
standards.”
Dr. Peter Mugyenyi, whose AIDS clinic in Uganda was a model for
Pepfar, called the deal “revolutionary.”
In 2001, Dr. Mugyenyi risked arrest under Uganda’s patent laws
by importing cheap AIDS drugs from Cipla. Two years later, he stood at Laura
Bush’s side during the 2003 State of the Union address as Mr. Bush described
his Pepfar plan to Congress.
“I can only compare this to that breakthrough,” Dr. Mugyenyi
added.
Overwhelmed Oncologists
A novel aspect of the deal is its attempt to overcome the severe
shortage of oncologists.
Oncologists in Africa cannot specialize; each must treat bone
cancer, cervical cancer, leukemia, and so on. But every treatment protocol is
many pages long — together they are far more than any doctor can memorize.
So Dr. O’Brien also recruited the National Comprehensive Cancer
Network, which brings together specialists from 27 top American cancer
hospitals to write guidelines and post them on
the web for use by oncologists everywhere.
Members are now splitting those guidelines into four tiers for
hospitals with different capabilities, said Dr. Robert W. Carlson, the
network’s chief executive.
In breast cancer, for example, “if you can’t do a mastectomy or
use tamoxifen, you probably shouldn’t even try to treat,” he said.
The next level would include tissue-sparing surgery, radiation
and basic chemotherapy; a third would include reconstruction with implants and
chemotherapy with monoclonal antibodies like Herceptin.
Members welcomed the chance to help, he said, because many
African doctors do their oncology residencies in the United States or Europe
and then stay, depriving their home countries of their skills.
“One big reason for the brain drain is that doctors get burned
out and frustrated, because they can’t provide the care they know they should,”
he said. “This should improve morale.”
IBM is helping by taking those guidelines and folding them into
its Watson supercomputing program.
Like tax-preparation software, it asks questions based on
entries like symptoms, lab results, biopsy results and so on, and then
generates the best treatment regimen possible with the hospital’s resources.
The program also scans medical journals to update itself without human help.
Slow Progress
Even with cheaper drugs, progress against cancer in Africa will
be slower than it was against AIDS, all parties to the deal warned.
AIDS is caused by a single pathogen that can be suppressed,
albeit not cured, with a daily three-drug pill.
Cancer — out-of-control multiplication of the body’s own cells —
comprises an entire family of diseases. Treatment often entails surgery,
radiation and chemotherapy involving complex mixes of drugs.
Kenya offers a glimpse at the possibilities.
Its national health insurance plan, which charges annual
premiums of $18 to $200 depending on income, began covering cancer only two
years ago. Now, about 8 percent of its payouts are for the disease.
Three years ago, patients could wait 18 months for radiotherapy
at Kenyatta National Hospital, the only one poor people could afford; many died
waiting. Now, with insurance covering radiation in private hospitals, the wait
is gone.
In Nairobi Hospital, a private institution that was once the
European Hospital, Christine Kimburi, a 42-year-old property manger with
11-year-old twins, rested comfortably in a bed getting an infusion for her
choriocarcinoma, a cancer of the uterine lining that erupted after a failed
pregnancy.
She had surgery and is on her fifth chemo round. Her national
insurance covers four rounds a year, and her husband’s covers four more.
With luck, that is all she will need. Choriocarcinoma is often
curable.
“The mass they removed was not cancerous — we thank God for
that,” she said. “And I’ve had nil side effects from the chemo.”
But Kenya remains exceptional.
When she first looked at treatment in Africa, Dr. O’Brien said,
“I was just blown away because so little attention was being paid.”
“In America, since the 1960s, we’ve turned cancer from this
frightening, inevitably deadly disease into something very fightable,” she
added. “That human triumph has not crossed the border into Africa yet.”
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